Overview of Atherothrombosis:
Atherothrombosis is a condition in which a blood clot, or thrombus, is formed on the wall of an artery. It is often pre-cursed by a condition called atherosclerosis in which plaques are formed on the walls of arteries. When one of these arterial plaques ruptures, an inflammatory response is induced in which platelet aggregation and fibrin production are stimulated, causing the blood to clot at the site (Carranza, 2006). This clot is called the thrombus, and can become large enough to partially or fully occlude the vessel wall. When this happens, the blood flow, and therefore oxygen flow, is reduced to the tissues distal to the clot. In addition, the thrombus may become dislodged, becoming an embolus, and travel to a narrower portion of the vessel and cutting off blood flow. Either way, the disruption in blood flow may result in angina, myocardial infarction, or stroke (Carranza(2006).
Patient Profile:
Mr. Smith is a 56 year-old retired business man. He is married and has two children in college. He is having a difficult time adjusting to retirement, and has been feeling depressed. He spends most of his time reading inside or watching television. He is overweight and does not like to exercise.
Chief Complaint:
Physician referred him to have his teeth cleaned.
Dental History:
Mr. Smith does not like to go to the dentist or do much at home. His whole life he has brushed either only once a day or some days not at all. He does not floss, although he occasionally uses a toothpick. His last dental exam was several years ago, and his last cleaning was about 7 years ago.
Medical History:
Patient Medication:
Aspirin: 81 mg taken daily for cardiovascular health, taken since 2008. Implications- decrease platelet aggregation and increased bleeding time. Contraindications- hypersensitivity to the drug or any component of the formulation
Lovastatin: 20 mg taken daily for high cholesterol, taken since 2009. Implications-erythema multiforme. Contraindications- hypersensitivity to the drug or any component of the formulation
It was decided that since the patient was on anticoagulation therapy, a medical consult would be sent out.
It was decided that the patient would be required to discontinue his aspirin regimen 5 days prior to dental treatment, and that his INR would need to be taken within 24 hrs of treatment (Wilkins, ). If the INR was less than 2.5, he would be safe to treat. Medical Update forms for each visit: Radiographs and DDS exam:
DDS Presentation: Patient is missing #1, #16, #17, & #32. Patient has an MO amalgam on #2, L amalgam on #7, O amalgam on #14 & #15, PFM crowns on #18 & #19, DO amalgam on #20, DO amalgam on #29, PFM crowns on #30 & #31.
Referral Form: Evaluate the following teeth: #8 M decay, #9 M decay, #10 MFL decay
Clinical Findings (as presented during second check in):
Extra-oral findings:none.
TMD: Slight popping of the jaw on right side patient states it is asymptomatic.
Maximum opening:48mm.
Intra-oral findings: Bilateral linea alba, slight mandibular tori and palatal torus, fissured tongue, slight hairy tongue.
Atherothrombosis
Gingival Description: Free- generalized erythematous, blunted with localized clefting on 7,10,21-24 and 26 with localized bulbous on mesial of #6 - Mesial of #11, edematous and shiny. Attached- generalized red, edematous, loss of stippling and shiny
MBI: 50%
Probing Depths: generalized 3-4 with localized 5-6 mm pockets
BOP: 80%
Recession: 1 mm recession on # 11, 2 mm recession on facial of # 7, # 10, # 13, # 24, # 26, 3mm recession on # 14.
Mobility: + 7-10, 22-27
Fremitus: + 7-10
Furcations: None.
Mucogingival Defect: None noted.
Angles Classification: Class I bilateral
Facial Profile: mesognathic
Salivary flow: Inadequate.
PI- 95% (See Oral Hygiene Assessment form above)
ADA II localized ADA III
AAP:Generalized slight with localized moderate chronic periodontitis due to plaque and calculus modified by localized open margin on the distal of #19.
MVC calculus code: URQ & ULQ: medium, LRQ & LLQ: medium heavy.
Critical Thinking: Treatment Plan: SOAP Notes:
S:Patient here to get his teeth cleaned referred by his doctor.
O:RMH, BP: 122/82, P: 75, R: 15
A: ASA III
P: Reviewed medical history. Patient needs a medical consult. Sent out medical consult to patients physician Dr. Jones
NV: gather assessments,FMX, DDS exam.............Case # 7
S:Patient here to get his teeth cleaned referred by his doctor. O:RMH, BP: 123/86, P: 78, R:17, E & I Extra-oral findings:none, TMD: Slight popping of the jaw on right side patient states it is asymptomatic Maximum opening:48mm, Intra-oral findings: Bilateral linea alba, slight mandibular tori and palatal torus, fissured tongue, slight hairy tongue. Gingival Description: Free- generalized erythematous, blunted with localized clefting on 7,10,21-24 and 26 with localized bulbous on the mesial of #6 - mesial of #11, edematous and shiny. Attached- generalized red, edematous, loss of stippling and shiny, MBI: 50%, Probing Depths: generalized 3-4 with localized 5-6 mm pockets, BOP: 80%, Recession: 1 mm recession on # 11, 2 mm recession on facial of # 7, # 10, # 13, # 24, # 26, 3mm recession on # 14. Mobility: + 7-10, 22-27, Fremitus: + 7-10, Furcations: None. Mucogingival Defect: None noted. Angles Classification: Class I bilateral, Facial Profile: mesognathic, Salivary flow: Inadequate. PI- 95% A: ASA III, ADA II localized ADA III,AAP generalized slight with localized moderate chronic peridontitis due to plaque and calculus . MVC calculus code: Maxillary medium, mandibular medium P: Gather assessments, FMX 18 films, DDS exam, second check in, nutritional counseling NV: PI, OHI, URQ with anesthesia..........Case # 7
S: Patient here to get his teeth cleaned referred by his doctor.
O: RMH, BP: 122/84, P: 75, R:16
A: ASA III, ADA II, AAP:Generalized severe plaque and calculus due to plaque and calculus. MVC calculus code: Maxillary medium, mandibular medium
P: PI, OHI, Scaled URQ with anesthesia, administered at total of 3.6ml of lidocaine 2% w/ vasopressor. Performed an AMSA, GP, and PSA on the right side of the mouth. Patient tolerated the procedure well and left the clinic in good condition.
NV: OHI, Scale LRQ with anesthesia
S: Patient here to get his teeth cleaned referred by his doctor.
O: RMH, BP: 124/83, P: 72, R:18
A: ASA III, ADA II, AAP:Generalized severe plaque and calculus due to plaque and calculus. MVC calculus code: Maxillary medium, mandibular medium
P: PI, OHI, Scaled LRQ with anesthesia, administered at total of 1.8ml of lidocaine 2% w/ vasopressor. Performed a Gow Gates on the right side of the mouth. Patient tolerated the procedure well and left the clinic in good condition.
NV: OHI, Scale ULQ with anesthesia
S: Patient here to get his teeth cleaned referred by his doctor.
O: RMH, BP: 126/84, P: 76, R:18
A: ASA III, ADA II, AAP:Generalized severe plaque and calculus due to plaque and calculus. MVC calculus code: Maxillary medium, mandibular medium
P: PI, OHI, Scaled ULQ with anesthesia, administered at total of 3.6ml of lidocaine 2% w/ vasopressor. Performed an AMSA, GP, and PSA on the left side of the mouth. Patient tolerated the procedure well and left the clinic in good condition.
NV: OHI, Scale LLQ with anesthesia
S: Patient here to get his teeth cleaned referred by his doctor.
O: RMH, BP: 125/83, P: 73, R:17
A: ASA III, ADA II, AAP:Generalized severe plaque and calculus due to plaque and calculus. MVC calculus code: Maxillary medium, mandibular medium
P: PI, OHI, Scaled LLQ with anesthesia, administered at total of 1.8ml of lidocaine 2% w/ vasopressor. Performed a Gow Gates on the left side of the mouth. Patient tolerated the procedure well and left the clinic in good condition.
NV: 4-6 week re-evaluation.
Patient Education of Disease:
OHI:
Bass Technique, Tepe Brush, daily Fluoride Rinses. During the OHI in regards to the Bass Technique we will start with the patient showing us how he is brushing. Then we will explain the importance of brushing and try and find ways to mtoviate the individual as the reason he is here now is due to a referral from his physician. We will review with the patient the importance of getting under the gums while brushing. We will reienforce the 45 degree angle. Then at future appointments we will quickly review the brushing technique and then move forward with new ways to improve the oral hygiene. We will also introduce the patient to the tepe brushes for the anterior region where he has open contacts. We will instruct the patient to be gentle when using the brush and to insert it between the teeth and slide it in between the teeth in order to remove all the plaque. Also we will remind the patient that he needs to rinse off the plaque that gets on the brush prior to using it in a new area. This will decrease his plaque score as well as give him the ability to get in between the teeth is a simple way. By using the tepe brush instead of floss allows the clinicians to get the patients buy in as they are easier. After the patient is able to show improvement on these two oral hygiene aids we will move to flossing. At each appointment we will have dialogue with the patient askign how each oral hygiene aid is working and as what he likes and dislikes in order to ensure that he will continue to use the products. We are also going to recommend that the patient use a fluoride at home rinse during his daily oral hygiene routine in order to mineralize the teeth and prevent anymore decay.
Prognosis and Why:
References:
Carranza, F. A., Klokkevold, P. R. Newman, M. G., Takei, H. H. (2006). Carranza's clinical periodontology 10th edition. St. Louis, MO: Saunders Elevier.
Wilkins, E. (2005). The clinical practice of dental hygiene, 9th ed. Baltimore, MD. Lipincott Williams and Wilkins.
Periodontal Case #7 - Atherothrombosis
Overview of Atherothrombosis:
Atherothrombosis is a condition in which a blood clot, or thrombus, is formed on the wall of an artery. It is often pre-cursed by a condition called atherosclerosis in which plaques are formed on the walls of arteries. When one of these arterial plaques ruptures, an inflammatory response is induced in which platelet aggregation and fibrin production are stimulated, causing the blood to clot at the site (Carranza, 2006). This clot is called the thrombus, and can become large enough to partially or fully occlude the vessel wall. When this happens, the blood flow, and therefore oxygen flow, is reduced to the tissues distal to the clot. In addition, the thrombus may become dislodged, becoming an embolus, and travel to a narrower portion of the vessel and cutting off blood flow. Either way, the disruption in blood flow may result in angina, myocardial infarction, or stroke (Carranza(2006).
Patient Profile:
Mr. Smith is a 56 year-old retired business man. He is married and has two children in college. He is having a difficult time adjusting to retirement, and has been feeling depressed. He spends most of his time reading inside or watching television. He is overweight and does not like to exercise.
Chief Complaint:
Physician referred him to have his teeth cleaned.
Dental History:
Mr. Smith does not like to go to the dentist or do much at home. His whole life he has brushed either only once a day or some days not at all. He does not floss, although he occasionally uses a toothpick. His last dental exam was several years ago, and his last cleaning was about 7 years ago.
Medical History:
Patient Medication:
Aspirin: 81 mg taken daily for cardiovascular health, taken since 2008. Implications- decrease platelet aggregation and increased bleeding time. Contraindications- hypersensitivity to the drug or any component of the formulation
Lovastatin: 20 mg taken daily for high cholesterol, taken since 2009. Implications-erythema multiforme. Contraindications- hypersensitivity to the drug or any component of the formulation
It was decided that since the patient was on anticoagulation therapy, a medical consult would be sent out.
It was decided that the patient would be required to discontinue his aspirin regimen 5 days prior to dental treatment, and that his INR would need to be taken within 24 hrs of treatment (Wilkins, ). If the INR was less than 2.5, he would be safe to treat.
Medical Update forms for each visit:
Radiographs and DDS exam:
DDS Presentation: Patient is missing #1, #16, #17, & #32. Patient has an MO amalgam on #2, L amalgam on #7, O amalgam on #14 & #15, PFM crowns on #18 & #19, DO amalgam on #20, DO amalgam on #29, PFM crowns on #30 & #31.
Referral Form: Evaluate the following teeth: #8 M decay, #9 M decay, #10 MFL decay
Clinical Findings (as presented during second check in):
Extra-oral findings:none.
TMD: Slight popping of the jaw on right side patient states it is asymptomatic.
Maximum opening:48mm.
Intra-oral findings: Bilateral linea alba, slight mandibular tori and palatal torus, fissured tongue, slight hairy tongue.
Gingival Description: Free- generalized erythematous, blunted with localized clefting on 7,10,21-24 and 26 with localized bulbous on mesial of #6 - Mesial of #11, edematous and shiny. Attached- generalized red, edematous, loss of stippling and shiny
MBI: 50%
Probing Depths: generalized 3-4 with localized 5-6 mm pockets
BOP: 80%
Recession: 1 mm recession on # 11, 2 mm recession on facial of # 7, # 10, # 13, # 24, # 26, 3mm recession on # 14.
Mobility: + 7-10, 22-27
Fremitus: + 7-10
Furcations: None.
Mucogingival Defect: None noted.
Angles Classification: Class I bilateral
Facial Profile: mesognathic
Salivary flow: Inadequate.
PI- 95% (See Oral Hygiene Assessment form above)
ADA II localized ADA III
AAP:Generalized slight with localized moderate chronic periodontitis due to plaque and calculus modified by localized open margin on the distal of #19.
MVC calculus code: URQ & ULQ: medium, LRQ & LLQ: medium heavy.
Critical Thinking:
Treatment Plan:
SOAP Notes:
S:Patient here to get his teeth cleaned referred by his doctor.
O:RMH, BP: 122/82, P: 75, R: 15
A: ASA III
P: Reviewed medical history. Patient needs a medical consult. Sent out medical consult to patients physician Dr. Jones
NV: gather assessments,FMX, DDS exam.............Case # 7
S:Patient here to get his teeth cleaned referred by his doctor.
O:RMH, BP: 123/86, P: 78, R:17, E & I Extra-oral findings:none, TMD: Slight popping of the jaw on right side patient states it is asymptomatic
Maximum opening:48mm, Intra-oral findings: Bilateral linea alba, slight mandibular tori and palatal torus, fissured tongue, slight hairy tongue. Gingival Description: Free- generalized erythematous, blunted with localized clefting on 7,10,21-24 and 26 with localized bulbous on the mesial of #6 - mesial of #11, edematous and shiny. Attached- generalized red, edematous, loss of stippling and shiny, MBI: 50%, Probing Depths: generalized 3-4 with localized 5-6 mm pockets, BOP: 80%, Recession: 1 mm recession on # 11, 2 mm recession on facial of # 7, # 10, # 13, # 24, # 26, 3mm recession on # 14. Mobility: + 7-10, 22-27, Fremitus: + 7-10, Furcations: None. Mucogingival Defect: None noted. Angles Classification: Class I bilateral, Facial Profile: mesognathic, Salivary flow: Inadequate. PI- 95%
A: ASA III, ADA II localized ADA III,AAP generalized slight with localized moderate chronic peridontitis due to plaque and calculus . MVC calculus code: Maxillary medium, mandibular medium
P: Gather assessments, FMX 18 films, DDS exam, second check in, nutritional counseling
NV: PI, OHI, URQ with anesthesia..........Case # 7
S: Patient here to get his teeth cleaned referred by his doctor.
O: RMH, BP: 122/84, P: 75, R:16
A: ASA III, ADA II, AAP:Generalized severe plaque and calculus due to plaque and calculus. MVC calculus code: Maxillary medium, mandibular medium
P: PI, OHI, Scaled URQ with anesthesia, administered at total of 3.6ml of lidocaine 2% w/ vasopressor. Performed an AMSA, GP, and PSA on the right side of the mouth. Patient tolerated the procedure well and left the clinic in good condition.
NV: OHI, Scale LRQ with anesthesia
S: Patient here to get his teeth cleaned referred by his doctor.
O: RMH, BP: 124/83, P: 72, R:18
A: ASA III, ADA II, AAP:Generalized severe plaque and calculus due to plaque and calculus. MVC calculus code: Maxillary medium, mandibular medium
P: PI, OHI, Scaled LRQ with anesthesia, administered at total of 1.8ml of lidocaine 2% w/ vasopressor. Performed a Gow Gates on the right side of the mouth. Patient tolerated the procedure well and left the clinic in good condition.
NV: OHI, Scale ULQ with anesthesia
S: Patient here to get his teeth cleaned referred by his doctor.
O: RMH, BP: 126/84, P: 76, R:18
A: ASA III, ADA II, AAP:Generalized severe plaque and calculus due to plaque and calculus. MVC calculus code: Maxillary medium, mandibular medium
P: PI, OHI, Scaled ULQ with anesthesia, administered at total of 3.6ml of lidocaine 2% w/ vasopressor. Performed an AMSA, GP, and PSA on the left side of the mouth. Patient tolerated the procedure well and left the clinic in good condition.
NV: OHI, Scale LLQ with anesthesia
S: Patient here to get his teeth cleaned referred by his doctor.
O: RMH, BP: 125/83, P: 73, R:17
A: ASA III, ADA II, AAP:Generalized severe plaque and calculus due to plaque and calculus. MVC calculus code: Maxillary medium, mandibular medium
P: PI, OHI, Scaled LLQ with anesthesia, administered at total of 1.8ml of lidocaine 2% w/ vasopressor. Performed a Gow Gates on the left side of the mouth. Patient tolerated the procedure well and left the clinic in good condition.
NV: 4-6 week re-evaluation.
Patient Education of Disease:
OHI:
Bass Technique, Tepe Brush, daily Fluoride Rinses. During the OHI in regards to the Bass Technique we will start with the patient showing us how he is brushing. Then we will explain the importance of brushing and try and find ways to mtoviate the individual as the reason he is here now is due to a referral from his physician. We will review with the patient the importance of getting under the gums while brushing. We will reienforce the 45 degree angle. Then at future appointments we will quickly review the brushing technique and then move forward with new ways to improve the oral hygiene. We will also introduce the patient to the tepe brushes for the anterior region where he has open contacts. We will instruct the patient to be gentle when using the brush and to insert it between the teeth and slide it in between the teeth in order to remove all the plaque. Also we will remind the patient that he needs to rinse off the plaque that gets on the brush prior to using it in a new area. This will decrease his plaque score as well as give him the ability to get in between the teeth is a simple way. By using the tepe brush instead of floss allows the clinicians to get the patients buy in as they are easier. After the patient is able to show improvement on these two oral hygiene aids we will move to flossing. At each appointment we will have dialogue with the patient askign how each oral hygiene aid is working and as what he likes and dislikes in order to ensure that he will continue to use the products. We are also going to recommend that the patient use a fluoride at home rinse during his daily oral hygiene routine in order to mineralize the teeth and prevent anymore decay.
Prognosis and Why:
References:
Carranza, F. A., Klokkevold, P. R. Newman, M. G., Takei, H. H. (2006). Carranza's clinical periodontology 10th edition. St. Louis, MO: Saunders Elevier.
Wilkins, E. (2005). The clinical practice of dental hygiene, 9th ed. Baltimore, MD. Lipincott Williams and Wilkins.